 pleasure to introduce our speaker today. This is Dr. Elizabeth Newman and the title of her presentation, When Art and Science Collide Towards a Political Philosophy of Humanized Birth. She is a senior lecturer in midwifery at the University of Newcastle. Her 20-year career includes midwifery practice, advocacy, teaching, and research. She has published widely in both academic and practice journals and been invited to speak at conferences and events. She is the lead author of Towards the Humanization of Birth, a study of epidural antigen useal in hospital birth culture, published by Paul Grave McMillan in 2018. Key areas of study are birth culture and environment, midwifery practice to support birth physiology, maternity, policy, politics, and technologies, and care ethics. It is such a great pleasure to learn from you today. Liz, thank you for being here and I'm just gonna hand over the presentation to you. Thanks, Red. And thanks so much too. Thank you. And thanks our Virtual International Day of the Midwifery for having me. Oh, you've gone, Red, completely. Remind me how I do this. I go full screen. Hang on. Full screen applications. Is that what I do? You can. Do you see the arrows there to control your slide? That's good. Yeah. Thanks, Celine, for loving the title. I was quite happy when I came up with that as well. So yeah, the conference this year is about the midwifery art and science. And as I was, you know, putting together the talk, it really kind of came together as I was thinking about what I might talk about when I was invited to come and talk to this conference. So I'm really pleased to be here. And yeah, thanks for having me. And I, so I'll just jump straight into it. I just want to acknowledge that I'm sitting on the lands of the Ghana people and the traditional custodians of the lands on which I'm seated. And I want to pay my respect to Elders Past and Present and pay my respects to any Aboriginal, Torres Strait Islander people in the world today in the in the room. So what I'm going to talk about today is why a political philosophy of birth. And I did think it might put some people off, you know, that whole kind of theory thing can be a little bit daunting or some people find it boring even. But I just think it's fascinating and really important. And I'm going to talk about that during the course of this talk. And I'm going to talk about the science of knowledge production and its effect on the art of midwifery practice. So that's where the collision happens. And then talk a little bit about this concept of the paradox of the institution. Then a little bit about this idea of rhetorical informed consent and how that contributes to dehumanised care. And then coming up with a bit of a solution which is to focus on care ethics and relationality. So some of this stuff and lots of you may have seen this already. So that my PhD was published as the book Towards the Humanisation of Birth. And I was also invited to do a series of articles for the practicing midwife to kind of, you know, distill that down a bit and and try and interpret that for practice in a more kind of useful way, I suppose. So they're available anyway. And why am I talking about political philosophy, you know, in a midwifery conference? And I think from this 20 years, you know, and it is actually my 20th year of practice, I realised. So, you know, I've really come to realise that we have to attend to these kinds of knowledges, political and philosophical, as much as we do to other kinds of analyses. And we've gotten really good at some of the other kinds of analyses. You know, we do systematic reviews, we do clinical evaluations, and I'm talking about midwifery here as a field. But we've done less of this other kind of work, generally speaking. I mean, I know it's out there, but it's just not around as much. So I'm going to touch on Fico a little bit as I go through this presentation. And so, you know, Fico kind of talked about philosophy as being a practice of politics. And in essence, it's a truth telling in relation to power. So we don't just kind of talk about what's happening or think about what's happening. You know, if we use philosophy, we can actually shape what's happening around us in the world by questioning, contesting and understanding the kind of truths that we have around us. Why is this important? And I don't really need to say this to probably anyone in this room. We know that birth trauma rates are going up. We know that obstetric violence reports are going up. We know that suicide is a leading cause of maternal mortality. And, you know, these are problems that we're facing all over the world. And at the same time, there have been, you know, mechanisms to try and reduce this kind of behavior. So the the re-huna there on the left is the with the humanization of birth network in Brazil that started, I mean, in the 90s. And, you know, the humanizing birth movement has been growing since then and really that was a kind of antidote to obstetric violence. So and at the same time the World Health Organization is publishing position papers on elimination of disrespect and abuse. We've got human rights and childbirth. We've got reproductive justice movement. And this has been going on at the same time. And yet we're still seeing these increased rates. So, you know, there's something else going on here. And that's where, you know, this kind of idea of the this science and art colliding comes in. Again, I'm just going to talk very quickly about some some simple kind of philosophical building blocks, I suppose, before I go into the the the more interesting bits about how it affects midwifery practice. But just to just to kind of set it up Ficoe talked about power as being a productive force. So it wasn't just this kind of oppressive thing that came down and, you know, told people what to do. It's productive. So and its main area of production is in the gathering and the storing of knowledge. And this is how power is is created and maintained. It's also localized. So he talks about techniques of power in institutions and between individuals. And the good thing about that is that every opportunity then is an opportunity for resistance. You know, every interaction with every person is an opportunity to think about power interactions. But so this gathering and storing of knowledge is a kind of surveillance technique that hospitals and prisons and schools and other social institutions sort of contribute to creating these these kind of techniques of power that then are used to govern behavior of populations. So if you just see that last little quote to structure the possible fields of action of others and this is what governance does. So at some point in this whole process, they don't even really need to govern because people are already busy governing themselves because we know what it means to be a good student or a good patient. And so these ideas about the way we need to behave become self-fulfilling. The other thing, the other point I suppose I want to talk about is genealogy. So Fico disrupted the idea that we're on this kind of path to progress, which was very much the kind of I suppose the ideas that came out of the Enlightenment in the scientific discourse was to say, you know, we're finding our way to this end point where we're going to know everything and it's going to be great. But Fico says, no, you know, we're not on this path to progress. We're actually just sitting in this constant struggle of knowledge and whichever knowledge creates itself as dominant seems self-evident. So it feels like it's just how things are. You know, the status quo, this is what happens. You have a baby, you go to hospital, you're going to be induced, blah, blah, blah, and it becomes less feasible to resist these kind of practices because they become common sense. And in this way, the problem for us is the more self-evident medicalised birth becomes the less other ways of birthing seem possible or acceptable. And I think we're seeing that a little bit now. I mean, it's always been there, but so dominant discourses recreate themselves using this power knowledge kind of paradigm and what that creates is history. It creates thought. It creates action. It creates the truth of our age. For example, it's safe to give birth in a hospital is one of those. And then if you have a radical or a dissenting view then you're not only denied access to the dominant discourse, but you're opposed and you're often discounted as kind of dangerous or foolish often. So medicine is a current dominant discourse. It's part of the general kind of politics of what of the truth of childbirth. You know, it creates norms. It creates rules. It creates ideas about what's safe and what's risky. And part of the reason that medicine could align itself in this way is because, you know, because of the history and again we're going to go back to that kind of patriarchal status driven thing. Because it was educated men mostly, medicine aligned itself with science and technology even though it wasn't particularly scientific, you know, in the 18th century for example. It's also aligned with government. So the government was started to become concerned with the surveillance of populations and so medicine was able to support that. So they supported each other. And as religion declined as a kind of institution of social control or social understanding, medicine came in and replaced that. So you can see the medicalization of sexuality and drug use and the areas that used to be much more under the kind of umbrella of the church. So if we take all this as kind of foundational then Faco would also say we don't need to think about the medicalization of birth as the problem itself but we need to think about what does the medicalization serve, what purpose does it serve, why does it happen, you know, who's interested in it. And to understand that we need to just briefly sort of understand that reproductive power is or reproductive issues are really a powerful piece of knowledge. So midwives would know about live and still births. They would know about who was trying to access abortion. They would know about paternity. They would know which you know kind of identifies property rights and things like that. Really powerful information. Midwifery power has been challenged by the church, the state, medical and nursing professions over the last sort of three or four hundred years in the Western European tradition at least. And again I'll go back to that idea that hospital birth is safe. When hospitals first came, were introduced they were definitely not safer. They had very high mortality rates, they were convenient for doctors, they were convenient for the state and yet we have this ongoing belief that hospitals are the safest place to give birth which is actually not based in any evidence whatsoever. And the brilliant midwifery research that's coming out now is saying actually probably not the safest place to have a baby also in Africa, Latisha, yeah. And a lot of that is colonisation as well. So other influences and there are many other influences but one of the important ones is techno-rationalism which I'll just briefly describe. So it's this idea that scientific advance is progress and remember Foucault said actually progress isn't real. It's only ever the struggle for knowledge but scientific advance equals progress and progress equals moral good. So there's this real kind of morality involved with science and technology. It also has an implied effectiveness of technological intervention so if there's machinery involved then you then it's got to be better. This is and the perfect example of this is CTG and the same with the next point the complex over the mundane. So the CTG is seen as more effective than a midwife in the room with a doppler or a pinards even though it probably not more effective. I'd say definitely not more effective. The technological imperative means just because the technology is there we think we have to use it and again CTG brings to mind but there are others and the prevention of abstract risk rather than the avoidance of a specific danger and this is quite important to remember because it takes away the focus from the individual and it moves it to the abstract and so the other thing that Foucault says about discourse is that all we really have to do to find out where the dominant discourse of the day is is to look at practice and you know this idea of thought as social practice. So if we look at current maternity practices around the world we can see where the dominant discourse is and this picture on this slide was just I just snapped it from Twitter the other month during the All Island Midwifery forum and that's the brilliant Mary Brosnan there from the National Maternity Hospital presenting you know and you know in a kind of you know a shocked sort of way that more first-time mothers will be induced or have a baby by pre-labour cesarean then will present in spontaneous labour and I mean that's just a snapshot and I pulled it off because you know I saw it but this is happening everywhere and it is a real problem I mean it is a massive issue we have no idea what we're doing and we've never been at this stage before in reproductive history so yeah so plainly we can see the dominant discourse that's operating and just so that you know that I'm not making this up I have got a paper about this which was written some time ago but it was about the Australian government tried to introduce some policy that would give midwives more autonomy and more scope and the medical system vehemently opposed it and they put in submissions about why obstetrics was rational safe and aligned with progress and why midwifery was dangerous dangerous ideological and needing supervision and in their first page of their submission they talked about mothers and babies dying if midwives were given more scope so really interesting there they also use other kinds of language so they talked about the government changes being interventionist which kind of draws on neoliberal you know freedom of the market kind of discourse they appealed to the to the women's right to choose but around epidural and caesarean section and they talked about the pressure they were worried that people would be pressured into a noble birth if midwives were given more scope and they made this whole argument on really minimal out-of-day and poor quality evidence so you can read about that if you want and that leads to this well I'm going to talk about the the science of knowledge production again it's about discourse and the way that we create truth so this is about epidural analgesia and some of you might have seen me talk about various elements of this because what I've done here is kind of pulled together all of the threads of you know what I've been doing the last few years and it kind of makes this story but anyway my apologies if you've seen bits of this before but um there's a little quote there on the front which came from a journal article a scientific journal article about epidural analgesia so that's quite I'm hoping you can all read read it but um it's fairly telling you know this it's very techno-rationalist wouldn't you say it's like you know part of the modern western lifestyle so then um part of this knowledge production thing so this is some of the work from my phd and I did a critical review of epidural analgesia so I didn't focus so much on the outcomes although I reported on them you know I did talk about what the impact was of an epidural but I was mainly looking for that the assumptions behind what they were saying you know so um part of that critical analysis is looking at what's kind of being said while even though they're trying to be unbiased and scientific all of the papers nearly all of them introduced epidural analgesia as a gold standard analgesia which I mean it probably is in the in the sense that it works quite well and it's um safer than a general anesthetic you know um they also talked about labor pain as being the worst pain that women will ever go through in their lives so that was really at the front of you know in the opening paragraph of these scientific papers so then um pain relief was constructed as paramount as as absolutely necessary um as it was kind of like the duty to relieve this dreadful pain and that it was nearly a human right pain relief was also equated to progress so which then meant that if you don't want to relieve pain you're kind of absurd or weird or archaic or some kind of you know living in a cave hippie so um and you can see there the discourse in action um there was an emphasis on the abnormality of labor pain so it um it created that as a kind of yeah this terrible thing that had to be had to kind of rescue people from um but it normalized technological intervention and did not ever talk about the pain of the intervention so there was a really old paper that's got you know the outcomes have got no relevance to today because it was related to a higher caesarean section rate which there doesn't seem to be an equation there anymore um because the blocks are lighter although in practice it's arguable because it looks like it leads to caesarean section a lot more but according to the the evidence it doesn't but anyway what these authors were saying was that the higher rates of caesarean section or instrumental birth were probably acceptable to women because uh at least it got rid of their labor pain so really bizarre ways of looking at pain especially when you think about the pain of caesarean scars or post-op recovery or apesiotomies and and trying to recover from those and it definitely ignored the positive and purposeful aspects of labor pain so when we finally got around to actually asking people what they thought about labor pain um they described it in people describe it in positive terms it's powerful it's joyful potentially you know not everybody but certainly strongly um there's a connection to the baby that um the most important thing in labor is actually support not pain and um that needing pain relief might actually come from fear or lack of control or lack of support rather than pain itself so that's the kind of flip side to to what the epidural literature was saying um okay so i mean we all know why you may not want to have an epidural main reason now i suppose is risk of instrumental birth but also other risks it doesn't necessarily increase birth satisfaction which is interesting because if it actually doesn't do that why would we be kind of saying that this is a good choice to make um we know that satisfaction with birth experience is not necessarily related to pain and it's multifaceted and so really when we think about it like that then the discourse about epidural as human right and a rescue kind of gets turned on its head and it's potentially an unnecessary intervention definitely not well explained to women and birthing people about what the risks are and it may not even relieve their suffering it may give them more suffering and it might decrease joy in birth or the possibility of joy because of the impact on the hormones yes so much for god's sake so then i did this other paper here and um uh this was about the language used in the pamphlets about water birth compared to the information that was given about epidural analgesia thanks to me um and essentially the the language that was talking about water birth in this particular site was all about risk and restriction and danger so it was you must you can't you know this is really dangerous you have to sign this in front of a midwife while you're still pregnant and the epidural information is very much about access safety and uh you could sign it whenever you know potentially after the epidural had gone in in labor so really different ways of framing these two practices even though you can get in a bath at home you know without any aseptic technique or anesthetic support um so when you look at them side by side of course getting in a bath is much less risky than having an epidural but it was not being presented like that so this again is this concept of risk discourse it's much broader than medicine it's part of our social kind of way of being now there's a few key theorists that talk about risk discourse and it's yeah it's bigger than medicine but when we bring it down to to a medical setting it's really abstract and inexact we can't say you know if there's a one in 10 000 charts of this happening we can't tell if the you know if the woman sitting in front of us is that one in 10 000 it really leads to a lack of individualization it leads to blanket policies that encourage over medicalization you know it again it focuses on technology it's quite practitioner centered it's about litigation and therefore it reproduces these power relationships an obstetric risk discourse in particular creates certain practices as risky and others as safe as i've just shown in that last paper medical practices tend not to be seen as creating risk so for example in my research induction was not really seen as a risky practice uh and there's a you know there's an example of that i won't go into it but um we can see it we can see that in the in the stats that i kind of had a few slides ago we are inducing women and birthing people at an alarming rate you know it's going up to 50 percent and over um the other thing about obstetric risk discourse is it's blind to genetic risk so it doesn't see the risks that it present in its own interventions and it's influenced by these other discourses like techno rationalism so rejection of technology is seen as risky even though it might be absolutely justified and the other thing to keep in mind is it's not evidence based at all mostly you know as a as a kind of general rule it's not about evidence it's about creating this kind of power knowledge discourse so then i thought about um you know this hospital system that i was studying and what i want to talk about here and it all links together and i'm hoping this is kind of clear i'm not um you know rambling about too much but essentially if you see on this left hand side organizational technology i've termed it because fico uses the terms uh technologies of power or techniques of power so it's about how our practice is organized to maintain the status quo in particular institutions so the organizational technology um used institutional surveillance so remember we talked about surveillance as being a part of the power knowledge collection you know that collection of information about people leads to a power knowledge situation so the way that they would do this is to well an example is for our EVs um or the kind of i don't know how many of you have seen like the kind of labor board boards that have got you know everyone's name on it and you know how dilated everybody is and this kind of overarching surveillance which is not really for the benefit of the woman it's for the benefit of the institution and what happens then if you see this other arrow that's going up institutional momentum so then what would happen is okay so that woman's not laboring fast enough let's get the cinto up or the the labor ward's filling up so let's get somebody you know to have a baby so we can get them out and get the next person in so what that actually did that surveillance paradoxically was increased risk for the women by by medicalizing the birth space um thanks Richard i'm just caught that little chat there then the midwifery technology on the other side was again paradoxical and that's why i've called this concept the paradox of the institution because the midwives were kind of like positioned as the people that had to take care of normal birth so um they you know there was kind of this banter about well you're a midwife you know go in there and don't come out to have had a baby i mean whoever's worked in the hospital may have um have i'm getting distracted by the chat may have um i heard that before you know it's like you know we're the experts of normal and that that's not kind of that's incorporated into this process okay midwife if you're a guardian of the normal go in there and get me out a baby this is you know the obstetric banter but then at the same time midwifery practice is constructed as risky this other arrow going up so midwives are tasked with this protecting physiology and yet every single practice that they need to pull out to to support physiology they're not able to do in that system or it's very difficult or there's a great resistance or it's kind of ridiculed and um you know um not really seen as beneficial so oh i've got 10 minutes i'm getting there thank you so there's this paradox whereby um things that are meant to keep women safe increase risk and the things that are meant to guard normal birth are not able to happen um which led me then to to see how and this this paper here was about how midwives talk about epidural use in antenatal classes which was kind of um you it's your body this is great physiological birth is fabulous um but you know and then the caveats would come hospital policy says this um you know it's really hard to get in the water and so on which made me really think about how can we talk about informed consent when everything from the from the main discourse in the scientific literature down through policy down to what the midwives are saying is kind of skewed in this institutional paradox way or this risk safety paradox way where safe practices are described as risky and risky practices are described as safe so then i wrote a paper with mavis kirkham about this where we talked about the problem of informed consent being essentially baseless or rhetorical because it's not actually happening which took us then to care ethics um so care ethics is a really useful way of looking at this problem because it gives primacy to the relationship um that's the main thing i'll say because i'm i need to sort of get through the rest of this but um it does see care as a political practice which is important because care it's then care isn't just about um that some people do for others you know mothers and babies midwives nurses everybody needs care everybody receives care everybody at some point will give care it's a political practice um that we that human beings do um so again the problem with autonomy is because is um the fact that it's kind of coming from this old colonizing kind of patriarchal thing that said you know we're all equal and we're all liberal individual humans but that really was only white men of particular means not everybody else was actually autonomous which means that bodily self-determination in places like hospitals and we see this in birth outcomes with black and brown women in the uk and Aboriginal women here having much worse outcomes because of these prejudices so autonomy is a problematic concept actually so some of us are saying actually obstetric violence is a problem of relationality rather than a problem of autonomy let's move this conversation forward how do we give um a relationship-based care in a system that is standardized and fragmented and again this is coming back to care ethics um and i want to just bring up bring your thoughts back to the the abstractness of the risk discourse abstract theory is a problem for relational care so bioethical principles are abstract we can morally detach ourselves and that's how dehumanizing practices like coercion and non-consent can happen if we put the relationship back in then it's much harder for that to occur so it's a key to providing ethical care and i'm going to focus on attentiveness if i've got time um so attention is an act of knowing and an act of love we need to talk more about love in midwifery we barely talk about it at all um and this act of attention of giving someone your attention enables them according to sererotic to let otherness be we can let or you know we don't let women do anything but we can um we can sit with women and birthing people's decisions when they don't align with care give a protocol or time restriction if we um if we just change our focus to attention to attentiveness and relationality um violence and coercive behaviors can't happen when you're paying attention with knowingness and love so identifying care as a political practice is part of care ethics it's it's as central to human life and it's a mechanism of resistance to dehumanizing systems which rely on abstraction and separation so instead we're bringing it back to complexity contextuality and human connection um and then i was just going to bring this quickly back to research because um you know i suppose back to this idea of a political philosophy we need to be thinking about theory we need to be thinking about qualitative research creativity and you know thinking of research in these deep reflective ways not just systematic kind of quantitative ways i think it's crucial to midwifery and birth especially where we're at oh my god three minutes critical midwifery studies i just want to acknowledge that there's lots of people doing things in this space Inge van Nysselroy is um uh introduced me to that sererotic piece i'm gonna just go to the end this is a crucial issue it's it's absolutely um with it's unprecedented and we think it's the same as climate change and that's my final slide why do we want a political philosophy i'll let you read that there do you want to have we got time for a question we have um thank you Liz we have two minutes um to be out of the room so we can run through um we can run through the chat and see what we have here there was a few questions there was so much resounding love for your presentation and how much you've put everything um together the red threads that you've brought in um thank you so let's start at the bottom here from Annabelle it says so Liz does it come back to genealogy um as Foucault suggests to deconstruct the patriarchal paradigms and reconstruct ethics of care ah yes you've said and then she said ah yeah i mean i think that's part of it i think there's yeah there are lots of kind of threads to this and i suppose what i'm trying to do is bring some of this thinking into the midwifery space and like i saw your question joe about how do we do this without pulling out Foucault all right i think we can do that you know and the um the papers that i wrote for the practicing midwife i really tried to just you know de-philosophize it but i suppose the point i'm trying to make is actually we can bring this in and have those and have those conversations and i think we need to bring the philosophy in actually maybe not with women and people and community but we need to understand how these bigger kind of structures are working so that we can actually resist them in a way that it's going to be effective because we know what the evidence is you know we know that these practices are happening we know that there's there are real problems so how can we address it in a way that is has kind of got a strong foundation and a strong argument so that we can really make change and this is just one way of doing it you know this is one person's thought but i just think we can pull it all together somehow and support each other to change the world really thank you Liz for being and for helping us to change the world i learned so much from you today and i feel like i need to listen to this presentation about five times um and yeah we need you in your work so much in the world so i'm so grateful for you it's been such a great conversation i know that we could we could do another 30 minutes easily another hour really easily and i am going to wrap us up now with